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AGH’s Medical Home Program Scores Formal Recognition

OCEAN CITY – Atlantic General Hospital (AGH) was recognized this month for its patient-centered medical home programs that currently benefit patients in many ways as well as attempt to lower medical costs in the future.

During a meeting with The Dispatch on Monday, AGH announced that two of its primary care physician practices, Townsend Medical Center and Berlin Primary Care, have received Level 1+ Recognition from the National Committee for Quality Assurance (NCQA) for their patient-centered medical home (PCMH) programs.

The Townsend Medical Center and Berlin Primary Care adopted the PCMH model in August of 2011 and are the first on the Eastern Shore to receive recognition from NCQA, the designated review body for the State of Maryland for PCMH.

According to AGH, the program is a team-based approach to caring for the whole person — mind, body, and soul. The concept features a team of healthcare professionals, guided by the primary care provider, providing comprehensive, coordinated care for the patient over his or her lifetime. This model actively embraces input and participation from the patient and the patient’s family. The PCMH team is structured to provide for all of a patient’s healthcare needs or work with other healthcare professionals to meet those needs.

“Your medical home is actually your primary care doctor,” AGH Clinical Manager Michelle Clifton said. “So knowing that is your medical home and knowing that you might have to go out and visit different specialties we always want that information to come back to your primary care so that one person has their finger on what is going on with your care.”

Clifton said AGH was fortunate enough to have a lot of PCMH aspects in place in developing the program along with an excellent clinical staff to work with.

“It was a matter of taking what they were already doing and putting it into a process, evaluating that process, and then enhancing it with an amount of things that benefit the patient,” she said.

Benefits include providing same day appointments and efficient tracking of diagnostic tests and referrals. A key tool in providing such an efficient

service is electronic medical records (EMR) where a medical facility participating in AGH’s program can easily pull up a patient’s information via computer. AGH has also taken on new staff members, or care coordinators, who act as medical navigators within the PCMH pilot program.

AGH furthered that the model has been developed to address inefficiencies in the current fragmented healthcare system in the U.S. In its current state, U.S. healthcare allows for the possibility of multiple disconnects among the various healthcare providers who might care for a single patient, which can result in duplicative testing and less than optimal management of chronic conditions. The PCMH focuses on a preventive, holistic approach and brings the disparate efforts together in a coordinated manner that makes better sense for each patient.

AGH Medical Director and Ocean City Family Physician Dr. Stephen Waters said he has witnessed the PCMH model allow doctors to practice the principles they learned in training to become family physicians and principles of care that were not always able to do because of the fragmented health care system.

“It is an attempt to put it in a model that allows us to practice better holistic care for a patient and I see it helping already with more complex patients,” he said. “We do have a fair number of elderly patients who have many health issues, many medications, and may not have good support … this is a huge issue for all of us and this is one attempt to provide better care and better support of a patient.”

Waters added that feedback from patients has been that they appreciate having an immediate contact for health concerns and feel less alone.

AGH CEO Michael Franklin pointed out that different pilot programs that the hospital is involved with do not include Medicare patients, which is the group that is in greatest need to be involved because studies show that they have the least level of health literacy or the least prepared to provide healthcare.

“It is not being funded for them to participate in these programs but on the other side this is when we need to become a model of care,” he said. “We can’t take care of people differently so we are developing a model of care that we are going to put throughout our practice and throughout the community. Our struggle still is one of their payment systems and insurance systems catching on with the type of care that is being delivered.”

PCMH is a three-year pilot program and there are about 50 medical facilities in the state participating. Such pilot programs are in place all across the country with the vision of eventually having the entire primary care community adopt this model for their patients.

Waters said the big question is what will be the conclusion following the pilot program. There are many organizations such as the federal government and different health insurance companies evaluating the program to see where it will head in the future of medicine in order to provide better care and lower health costs.

AGH explained PCMH was designed to decrease the healthcare cost burden. By coordinating care among a patient’s specialists and healthcare centers, diagnostic results can be shared rather than repeated. Ongoing health conditions can be better managed, thus avoiding more intensive, and therefore expensive, care.

“With the goal being in the long run that some of these patients can self-manage better and get the care that they need by not having to go to an emergency room by catching things earlier … which makes the patient healthier and it’s also healthier for our health systems in that we lower those high costs for emergency and inpatient visits,” Clifton said.

Franklin simply stated PCMH is a better way to keep people healthy and out of the hospital, especially those with a chronic illness, such as heart disease or diabetes, who are more prone to an acute problematic episode.

“Those are the people that are at higher risk to have an acute episode that brings them to an emergency room, and causes them to end up being in the hospital, which causes health care costs for them to go up,” he said. “This is a way of giving them more support outside of the hospital and giving the family more support outside of the hospital so they stay well and that makes life better for them and it puts less demand on the health care system.”